International Journal of Psychology and Behavioral Research. Vol., 3(3), 159-165, 2014
Available online at http:// www. ijpbrjournal.com
ISSN 2322-4002 ©2014 Victor Quest Publications
Effectiveness of Mindfulness Based Cognitive Therapy on Female
Elementary Students with Generalized Anxiety Disorder
1
2
3
Fahimeh Dehghani , Shole Amiri , Hossein Molavi , Hamid Taher Neshat-Doost
3
1. Department of Psychology, University of Isfahan, Isfahan, Iran
2. Associate professor, Department of Psychology, University of Isfahan, Isfahan, Iran
3. Professor, Department of Psychology, University of Isfahan, Isfahan, Iran
Corresponding Author Email: [email protected]
Abstract
The aim of the present study was to investigate the effectiveness of
mindfulness-based cognitive therapy in reducing generalized anxiety in female
elementary students. This clinical trial was conducted with the participation of
14 children with generalized anxiety disorder in Isfahan. They were randomly
assigned to two mindfulness based cognitive therapy group (7 individuals)
and control group (7 individuals). Participants’ worry and anxiety was
assessed using Pennsylvania State Worry Questionnaire-Child version and
Revised Children’s Manifest Anxiety Scale at pre-test, post-test and two
months after intervention. Covariance analysis was used to analyze data. The
results indicate that mindfulness training significantly decreases the worry
and anxiety in children with generalized anxiety disorder. The obtained results
confirm the effectiveness of mindfulness-based cognitive therapy on
generalized anxiety disorder in female elementary students.
Keywords: Mindfulness-based cognitive therapy, Generalized Anxiety Disorder,
Worry, Anxiety, Elementary students
Introduction
Generalized anxiety disorder (GAD) is a prevalent, disabling and often severe mental disorder in
children and adolescents (Wittchen, 2002). The main characteristic of GAD in diagnostic and
statistical manual of mental disorders (DSM-IV) is persistent (6 months or more), excessive and
uncontrollable anxiety and worry about a number of events and activities. This feature is
accompanied by various physiological symptoms, such as headaches, muscle tension,
restlessness, difficulty concentrating, irritability, and sleep disturbance. As with other anxiety
disorders, the symptoms of GAD must cause significant impairment in one or more areas of
functioning in order to meet diagnostic criteria (American Psychiatric Association, 2000). GAD
occurs over than 10% of children and adolescents. Age mean of its onset is 8.5 years, and girls
often more reported GAD than boys (Keeton et al., 2009).
Children with GAD are often self-critical (kendall et al. 1999), this characteristic leads youth to
avoid activities where they feel may not be able to perform perfectly and to seek excessive
reassurance from others about their performance (Flannery-Schroeder, 2004). Moreover, children
Intl. J. Phys. Beh. Res. Vol., 3(2), 159-165, 2014
and adolescents with GAD due to perfectionism, self-doubt, self-imposed high standards, and
fear of failure may spend a lot of time to end homework assignments (Albano & Hack, 2004).
Anxiety disorders aren’t transient and, if untreated, may be associated with long-term negative
effects (Kendall et al, 2006). These disorders are rarely recover without treatment and effect
different aspects of life, including academic performance, social interactions, self-esteem and
ability to enjoy life experiences (Pahl & Barrett, 2010). In students with anxiety disorders,
impairment in the function may seen in absence from school, avoid going to school, poor
academic performance or grades lower than what is expected for children based on their ability
(Mazzone, 2011). Because of the high prevalence of anxiety disorders in children and the
persistence of them over the time, early diagnosis, treatment and prevention programs are
needed.
There are various psychological interventions for the treatment of anxiety disorders in children.
Mindfulness based therapies are interventions that recently received much attention. Mindfulness
can broadly be defined as paying attention in a particular way: on purpose, in the present
moment, and nonjudgmentally (Kabat-Zinn, 1994). Mindfulness based interventions include many
methods for teaching mindful awareness (Baer & Krietemeyer, 2006). Through the practice of
mindfulness, intentional awareness of the present moment experience is increased (Kabat-Zinn,
1982). In other words, mindfulness is focused individual attention on the present moment and
helps the individual accept events without trying to change them (Allen & Knight, 2005).
Mindfulness-based therapies are generally effective in reducing anxiety, stress, and depressive
symptoms in adults (Baer, 2003) but researchers are just beginning to explore the acceptability
and effectiveness of this approach for children. However, the available clinical trials suggest that
mindfulness techniques are useful in treating anxiety symptoms in school age children
(Goodman, 2005; Semple et al., 2005).
Mindfulness-Based Cognitive Therapy for children (MBCT-C) is a manulized group therapy
developed to enhance attention and reduce anxiety for children age 9-13 (semple & Lee, 2011).
This therapy adapted from MBCT treatment program for adults (Segal et al., 2002). MindfulnessBased Cognitive Therapy (MBCT) is a manualized treatment that integrates mindfulness
techniques and elements of cognitive-behavioral therapy (Segal et al., 2002). In the adaptation,
several key developmental differences were addressed in conducting psychotherapy with schoolaged children (lee et al., 2008).
With regard to the importance of early interventions on mental disorders in children, the aim of
the present research is to investigate the effectiveness of mindfulness based cognitive therapy in
reducing worry and anxiety of female elementary students with generalized anxiety disorder.
Method
The method of study is semi-experimental with pre-test and post-test and control group
design. The statistical population of this research included all 9 year-old female elementary
students of one of the region of Isfahan. Area 3 was selected from among the five areas of
education in Isfahan through multi-stage cluster random sampling method. Among female
students in third grade who responded to the Screen for Child Anxiety Related Emotional
Disorders (SCARED) questionnaire, 33 students were identified and then assessed through the
Interview to ensure that they have generalized anxiety disorder. Finally 14 patients with GAD
were randomly assigned to two experimental groups (MBCT-C) and a control group. The
experimental group participated in twelve 90-minute MBCT-C sessions and the control group
received no intervention. This intervention is a 12-session manulized group therapy that
appropriate for seven to eight children. The aims of the early sessions familiarize children with
mindfulness and establish a safe environment for member groups. Theme of the following
sessions consist of identifying thoughts, feeling and body sensations, differentiating between
judging and describing, practicing directing attention and learning how to stay present. The last
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sessions focus on integrating and generalizing mindfulness in to everyday life (Semple et al.,
2006). All subjects completed the questionnaire at the pre-test and post-test phases.
Measures
The Screen for Child Anxiety-Related Emotional Disorders-Child version (SCARED): This
questionnaire consists of 41 self-report items rated on a three-point scale. The SCARED
assesses the symptoms of four DSM-IV disorders (panic disorder, generalized anxiety disorder,
separation anxiety disorder, social anxiety disorder) and school avoidance. Psychometric
properties of the SCARED in both community and clinical samples was good (Birmaher et al.,
1999; Isolan et al., 2011). SCARED has been validated in Iran and has demonstrated good
psychometric properties (Dehghani et al., 2013).
Penn State Worry Questionnaire for Children (PSWQ-C): The PSWQ-C is a 14-item
questionnaire for measuring whether children have excessive, generalized, and uncontrollable
worries. The Items are scored on a 4-point scale: 0=never, 1=sometimes, 2=often, and 3=always.
Higher points indicate a higher tendency to worry (Chorpita et al., 1997). Reliability and validity of
this questionnaire were assessed in Iran (Mofrad, 2000).
The Revised Children’s Manifest Anxiety Scale (RCMAS): RCMAS is a 37-item self-report
measure designed to assess the symptoms of anxiety. The participant answers either "yes" or
"no.", and scores range from 0 to 28, with higher scores representing greater anxiety. It has been
shown that this scale has good psychometric properties and to provide elevated scores for
children experiencing anxiety in comparison to non-clinical control children (Reynolds &
Richmond, 1978). RCMAS has been already validated and used in Iran (Taghavi & Alishahi,
2004).
Results
Mean and standard deviation of worry and anxiety scores of treatment and control groups at
pre-test and post-test are shows in Table 1.
Table 1. Mean ± SD of worry and anxiety Scores in GAD Female Elementary Students at PreTest and Post-Test
Mean (Standard
Variable
Phase
Group
Deviation )
Experimental
25.83 (6.27)
Pre-Test
Control
24.14 (3.62)
Worry
Experimental
20.16 (6.24)
Post-Test
Control
23.14 (4.22)
Experimental
16.50 (3.27)
Pre-Test
Control
15.14 (3.53)
Anxiety
Experimental
11.33 (3.08)
Post-Test
Control
14.71 (4.23)
As seen in Table 1, the Mean (±SD) of worry variable at pre-test phase for the experimental
and control groups were 25.83 (6.27) and 24.14 (3.62), respectively. The Mean (±SD) of worry
variable at post-test phase for experimental and control groups were 20.16 (6.24), and 23.14
(4.22), respectively. The Mean (±SD) of anxiety variable at pre-test phase for the experimental
and control groups were 16.50 (3.27), and 15.14 (3.53), respectively. The Mean (±SD) of anxiety
variable at post-test phase for experimental and control groups were 11.33 (3.08), and 14.71
(4.23), respectively.
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To evaluate the efficacy of mindfulness therapy on worry and anxiety, analysis of covariance was
used to control the effect of pre-test. For using of analysis of covariance two assumptions werw
assessed. Shapiro-Wilk and Levene’s test were used to test homogeneity of variance and
normality of data. The results showed that these two assumptions are hold and we can use the
analysis of covariance. The results are shown in Table 2.
Table 2. The results of univariate covariance analysis on the scores of worry and anxiety of two
groups in the post-test
Variable
Sum of
Squares
Mean of
Squares
F
Sig.
Etasquared
Observed
Power
Worry
65.38
32.69
5.02
.020
.38
.73
Anxiety
75.89
37.94
5.69
.014
.42
.79
As seen in Table 2, there is a significant difference between worry of students of experimental
and control groups at post-test phase with controlling pre-test (P = 0.02). Therefore according to
the mean worry of students in experimental group at post-test compared with control group,
mindfulness therapy decreases worry in the experimental group. Also, the results of covariance
analysis in table 2 indicated that exists significant difference between the experimental and
control groups in terms of anxiety in post test (P=0.14). This result show that mindfulness therapy
decreases anxiety in the experimental group.
Discussion
The aim of this study was to investigate the effectiveness of mindfulness based cognitive
therapy in reducing worry and anxiety of female elementary students with generalized anxiety
disorder. The results of analysis of covariance showed that by controlling pre-test, a significant
difference is observed between female elementary students of experimental and control groups at
post-test phase in terms of worry and anxiety (P < 0.05). In other words, mindfulness based
cognitive therapy reduces worry and anxiety in experimental group. No study was found to study
effectiveness of mindfulness based cognitive therapy on generalized anxiety disorder in children
but our findings is consistent with the results of similar studies such as semple et al. (2005),
Napoli et al. (2005), Vøllestad et al. (2011), Biegel et al. (2011) confirming the effectiveness of
mindfulness interventions in reducing the symptoms of anxiety in children. Also Anderson et al.
(2007), Evans et al. (2008), Kim et al. (2009), and Sharma et al. (2012) in adults show similar
findings.
Research indicates that individuals with GAD evaluate their internal experiences (thoughts,
emotions, and physiological sensations) negatively, and use worry as a means of escaping or
avoiding these experiences (Mennin et al., 2005). Roemer and Orsillo (2005) also states that,
GAD is maintained through problematic and reactive relationships with internal experiences and
internal and behavioral responses aimed at avoiding and decreasing distress. Non-acceptance of
negative emotions and tendency to avoid experiencing aversive emotions (i.e., Worry and
anxiety) may also function as a mechanism through which mindfulness influences symptoms of
generalized anxiety disorder. In fact, viewing the thoughts that related to worry without judgment
about them can lead to the understanding that thought just thought and not a reflection of reality,
therefore not necessarily to be avoided. Practicing mindfulness skills increase the ability of clients
to tolerate negative emotional states and enable them to cope effectively. Kabat-zinn, et al.
(1992) suggested patients who are able to identify anxious thoughts as thoughts, rather than as
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reality, report that this alone helps reduce their anxiety and increases their ability to encounter
anxiety-producing situations more effectively.
Worry the central defining feature of GAD is future focused whereas mindful attention is
centered on the present moment (e.g. Borkovec et al., 1983). The focus of MBCT-C exercises is
broadly on redirecting participants’ attention toward the present moment and changing their
relationship with thoughts, feelings, and current experience. The aim of using several sensation
exercises in MBCT-C is focused attention in the present moment. On the whole, our results
suggest that mindfulness based cognitive therapy might be useful for elementary students with
generalized anxiety disorder.
The present research had some limitations; our sample population was only female
elementary students. Therefore, we can’t generalize the results to other populations. Also we
examine the efficacy of MBCT-C on generalized anxiety disorder. It’s recommended that the
effectiveness of mindfulness intervention on other anxiety disorders of children is studied.
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